Eluding Meaninglessness: A Note to Self in Regard to Camus, Critical Care, and the Absurd

https://doi.org/10.7812/TPP/13-106

Abstract

Here I present a medical narrative, as a catharsis, regarding Albert Camus's The Myth of Sisyphus in an attempt to elude meaninglessness in my difficult everyday practice of critical care medicine. It is well documented that physicians who practice critical care medicine are subject to burnout. The sense of despair that occasionally overwhelms me prompted my rereading of Camus's classic text and caused me to recount his arguments that life is meaningless unless one is willing to take a leap of faith to the divine or, alternately, to commit suicide. This set up the examination of his third alternative, acceptance of a life without prima facie evidence of purpose and meaning, a view that may truly have some bearing on my professional life in the intensive care unit.

Introduction

All life ends. I spend most of the hours of my days trying to delay or avoid the inevitable on behalf of my patients in the intensive care unit (ICU). At times I can put it off for days; sometimes I can help put it off for decades. Physicians who practice critical care medicine (intensivists) are at the forefront of treatments that confront the complicated, the futile, the end of life, hopefulness (and hopelessness), and, at times, a search for the meaning of such efforts. As an intensivist I live in the present. I try to get my critically ill patients through the day. I formulate treatment plans with foresight, but I know that setbacks occur in the care of such patients. At the end of the day I hope that things have gone better than the day before. In effect, an intensivist cannot live anywhere but in the present, and in this "present" I contemplate the effectiveness of my efforts, and at times the futility of these efforts that I struggle with on behalf of my patients and their families. I realized that as an intensivist I am subject to burnout.1 So I made a note to myself to locate an old text that I had read in my youth and to reread it: The Myth of Sisyphus by Albert Camus.2 I recalled that its content struck a bell somewhere in my remote memory in regard to my current situation.

Upon reexamination of this text I came away a little disturbed because I could see parallels in Camus's arguments that apply to my practice of critical care medicine, especially in times of despair. I truly try to elude the feelings of meaninglessness that his dialogues address. Camus claims we will never find the meaning we seek. He insists we need to make a leap of faith and place our trust in God or conclude that life has no meaning, thereby allowing ourselves no alternative but to commit suicide (because life is meaningless). Indeed, there are times when my efforts seem meaningless, especially when I cannot get a good result for my patient or if I cannot get the patient's family to understand that there will be no meaningful result for their loved one. In these cases the universe remains deafeningly silent. Even if I wish to make that leap of faith to the divine in order to help me understand that there is meaning to this existence, Camus's arguments lead me to believe that he is correct on some philosophical level (understanding that he was a novelist who had a philosophical perspective and that I am a physician who dabbles in philosophy at the edges, which makes neither one of us philosophers—me less so than him, but both have an appreciation of the fact that we need to know not so much how we do things but why). I struggle daily to fight back against Camus's perspective on these matters.

What really interested Camus was starting a discourse on his third alternative. He poses the interrogative, "Can we accept a life without purpose and meaning and continue our existence?"2:p10-63 This is quite an intellectual quagmire for an intensivist. It may be that Camus's third alternative can come to pass, albeit not entirely on Camus's terms.

Discussion

In The Myth of Sisyphus, Camus points out that there is an absurdity that humans face in that we seek meaningfulness in the things we do but the universe remains silent in the face of our queries. Humans are not absurd, and neither is the human mind, but as we seek clarity in regard to our surroundings, actions, and existence in a world that does not seem rational to us, we encounter silence and irrationality from our universe. According to Camus, the absurdity is this conflict, or confrontation, between this search for meaning and its concealment from us. An intensivist must live with this contradiction and must struggle against it. This contradiction cannot be reconciled; being aware of it is all I can do (Camus's above-mentioned third alternative). In other words, the successful intensivist does live in the moment the vast majority of the time. Critical care medicine requires an intensity of purpose and focus. By living in the moment and by concentrating on helping my patients, I elude meaninglessness—or so I think. I am successful in doing so by acknowledging my conflict with the absurd and living my life fully in the face of it.

According to Camus, the three characteristics of the absurd life are revolt, freedom, and passion.2:p64-85 Examples of the absurd life presented by Camus in The Myth of Sisyphus include the seducer, the actor, the rebel/conqueror, and the writer. Here I will confine myself to using the example of the conqueror because it seems appropriate in reference to the mission and personality type of intensivists (conquerors of disease/critical illness).

In regard to revolt, I can hope for unity and order, but I must realize that it will never come to pass. Camus tells me that I cannot accept any answer or reconciliation in my struggle, that I live in a state of perpetual conflict, a state of revolt with no hope—it is the absurd. Although this may not make sense to many, in the ICU I confront this consequence daily.

How so? First, I provide care for patients for whom I know death or disability is a probable outcome, yet their families push me to engage in maximizing futile care, and I acquiesce. I understand that this is wrong on a medical, social, ethical, and economic level, but I do not deny them that care nor deny the family their wishes. I hint, cajole, plead, and try to bring the family to an action (or inaction). I struggle against death and disability even when we know there is no hope of success.

Second, many ICUs actually lack goals of care for the patient (goals that palliative care teams can provide if used appropriately). Without goals of care, the ICU environment becomes an arena for the provision of high-intensity care. In other words, every laboratory test and every number is corrected, regardless of any apparent futility (there are low-intensity care units where goals of care take priority and the end of life is not based on a lab test, but is a failure to achieve the aforementioned goals of care).3 The ICU team wades in against the inevitable, waiting for a condition of unity and order that will never appear. Therefore, in regard to Camus's view of revolt, he will find a sympathetic ear on my part.

Camus claims that men and women should be free to do anything they wish because life has no value or meaning. In other words, every minute of one's life should be free of constraint. Camus keeps his ideas of freedom on an individual/nondivine level and forgoes imbuing his thoughts with the concepts of the divine or rational thought. Freedom, in the ICU, can be linked to a Camusesque political struggle (in many ways similar to Camus's conqueror). These political struggles many times are between the intensivist, the family, the primary care team, and the hospital administration or any permutation thereof. This freedom and political struggle are connected. I constantly wish to act as I see fit in regard to the patient's best interests and wish to act without constraint in their behalf. I try not to have regulations, statutes, and orders that are thrust upon me by outside forces prevailing on my practice. This is frequently not possible.

I work with many suffering patients and, at times, I am left with some level of despair, in that 45% of all patients who are dying do not realize it, 22% of patients in the US die in ICUs, and up to 58% die in hospitals.4-6

However, the reason that I continue to persist in my curative and resuscitative efforts must be because, at some level, my self identifies the work I do as important, regardless of the fact that there is concealment of any value or meaning. Nonetheless, I struggle against this concealment. But here Camus may err to a degree. I am free to help patients because I choose to do so. There is nothing metaphysical about this. It is a rational choice, devoid of the divine. No one makes me do it. I choose on a daily basis to enter the daily critical care grind of my own volition. I am free of constraint or action. My actions have nothing to do with conformity.

The passion of the moment is very real in critical care medicine. The absurd man or woman will live only in the present, with no concern for the future or the past. The present is the only time of importance. If life has no meaning then living fully in the present is the best that I can do. The present then has more intensity. That is very appropriate in my line of work. This allows Camus to make the argument that passion occurs because of the quantity of experiences in the present. Even though I may fight this, I do indeed live in the present. An intensivist seems to need to do so. The future and the past do not preoccupy me in my daily duties. When a patient is in extremis, or on an identifiable death trajectory,7 I can only live in those immediate moments. An intensivist usually takes a 7- to 14-day rotation, and in that 1 to 2 weeks there is little time to look back or to look forward. If a patient dies, it is truly a most unfortunate event, but I must complete rounds, take new patients, and face the postmortem analysis at a much later date (usually at a monthly meeting). Here there is pressure to acquiesce to the arguments of Camus in his perception of passion to avoid the meaninglessness of absurdity. In critical care medicine there is a vast quantity of moments. These moments do serve to make me live in the present and to live my professional life to the fullest.

Even though I feel the qualitative absurdity of my quantifiable experiences, I continue to struggle with what is meaningful and doable. Is it possible for me to live with merely what I know? In most situations, even if I did hope for divine intervention, it probably would not arrive; but, of course, I would not contemplate suicide under these circumstances. My frustration does, in fact, lead to revolt (at least intellectually). The truth in regard to my freedom is that it is constrained in the arena of patient care (although maybe not in my personal life) even though I am absolutely free to think and behave as I choose. The vast majority of us do what we can in the present on the basis of our experience (quantity), which is a source of passion. With regard to the practice of medicine in the ICU environment, Camus may falter a bit on freedom, but as to revolt and passion he scores well. However, any attempt on my part as to a conclusion merely leads to more questions. Am I like Sisyphus? Do I just roll a rock up a mountain only to have it roll back down at the end of a long, hard day? Do I struggle for my patients without hope of success? Is there more for me than these daily struggles?

In this narrative I take a Camusesque look into my self, because his work The Myth of Sisyphus struck a chord in the deepest, most reflective portion of my self. All of us who provide health care occasionally reach down deep into our being and seek an answer or explanation only to find that the cosmos comes up wanting. Especially when it comes to an explanation to soothe our innermost frustrations and conflicts.

Conclusion

Reflection through medical narratives, particularly a disquisition of 21st century dialectics and discourses interpreted through the eyes and examination of thinkers and doers who predated us may be a source of resolution, explanation, or comfort for those of us who struggle with the ethics, conflicts, and concerns of modern-day medical situations and controversies.

Although Camus rejects the metaphysical and insists on asking me (from the grave) if I can accept a life that, from his perspective, is without purpose and meaning (thethird alternative), I can only respond to him in the affirmative. I go through my long, busy workdays in the ICU without thinking about anything metaphysical, let alone divine. Whether I believe in God is essentially irrelevant in this context. People are sick. They need to be cared for. The job needs to get done. I am absolutely focused on the task at hand.

Furthermore, I am not committing suicide because my rebelliousness, freedom, and passion do indeed keep me interested, concerned, connected, and engaged. I do not expect anything or anyone divine to step up and solve my problems or to save my patients. So yes, Mr Camus, I am happy. I am not impaired or paralyzed by the thunderous silence of the cosmos. And no, Mr Camus, I am not going anywhere tonight, except to bed. I am going to get up in the morning, have my cup of coffee, and go back for another busy day of stamping out disease and pestilence—meaninglessness eluded.